To send this article to your account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.
Find out more about sending content to .

To send this article to your Kindle, first ensure no-reply@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle.
Find out more about sending to your Kindle.

Note you can select to send to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

By using this service, you agree that you will only keep articles for personal use, and will not openly distribute them via Dropbox, Google Drive or other file sharing services.
Please confirm that you accept the terms of use.

There is an increasing appetite for a change in the law to allow assisted
suicide. This editorial suggests that psychiatrists should engage in the
debate because the issues at stake will affect us, and we are likely to have
a significant part to play were the law to be changed. We suggest that there
are three main areas where psychiatrists' expertise may be informative: (a)
the extent to which safeguards to limit the availability of assisted dying
to target groups can be applied safely and fairly, including to individuals
with psychiatric disorders; (b) the complexities inherent in assessing
mental capacity; and (c) the degree to which individuals adapt or change
their desires, particularly in relation to suicidal behaviours.

The idea that psychotic disorders are characterised by progressive
neurodegeneration that can be reversed by drug treatment is used to justify
early treatment of increasing numbers of mostly young people. I argue that
there is little evidence to support the view that old- or new-generation
antipsychotics are ‘neuroprotective’, and some evidence that the drugs
themselves may be responsible for the decline in brain matter observed in
some studies.

The Movement for Global Mental Health is a coalition of individuals and
institutions committed to collective actions that aim to close the treatment
gap for people living with mental disorders worldwide, based on two
fundamental principles: evidence on effective treatments and the human
rights of people with mental disorders.

Improving access to psychological treatments for common mental disorders is
a priority in a number of countries worldwide. We consider the evidence
presented by Harris et al on the Australian Better Access initiative, and
discuss the challenges of delivering such intitiatives and evaluating their
impact.

Individuals with repetitive or impulsive aggression in the absence of
other disorders may be diagnosed with intermittent explosive disorder
according to DSM–IV, but no such diagnostic category exists in ICD–10.
Mood stabilisers are often used off-license for the treatment of
aggression associated with a variety of psychiatric conditions, but their
efficacy in these and in idiopathic aggression is not known.

Aims

To summarise and evaluate the evidence for the efficacy of mood
stabilisers (anticonvulsants/lithium) in the treatment of impulsive or
repetitive aggression in adults.

Method

A meta-analysis of randomised controlled trials that compared a mood
stabiliser with placebo in adults without intellectual disability,
organic brain disorder or psychotic illness, identified as exhibiting
repetitive or impulsive aggression.

Results

Ten eligible trials (489 participants) were identified A pooled analysis
showed an overall significant reduction in the frequency/severity of
aggressive behaviour (standardised mean difference (SMD) =–1.02, 95% CI
−1.54 to −0.50), although heterogeneity was high (I2 = 84.7%). When analysed by drug type, significant effects
were found in the pooled analysis of three phenytoin trials (SMD =–1.34,
95% CI −2.16 to −0.52), one lithium trial (SMD =–0.81, 95% CI −1.35 to
−0.28), and two oxcarbazepine/carbamazepine trials (SMD =–1.20, 95% CI
−1.83 to −0.56). However, when the results of only those studies that had
a low risk of bias were pooled (347 participants), there was no
significant reduction in aggression (SMD =–0.28, 95% CI −0.73 to 0.17,
I2 = 71.4%).

Conclusions

There is evidence that mood stabilisers as a group are significantly
better than placebo in reducing aggressive behaviour, but not all mood
stabilisers appear to share this effect. There is evidence of efficacy
for carbamazepine/oxcarbazepine, phenytoin and lithium. Many studies,
however, were at risk of bias and so further randomised controlled trials
are recommended.

In 2006, Australia introduced new publicly funded psychological services
for people with affective and anxiety disorders (the Better Access
programme). Despite massive uptake, it has been suggested that Better
Access is selectively treating socioeconomically advantaged people,
including some who do not warrant treatment, and people already receiving
equivalent services.

Aims

To explore potential disparities in Better Access treatment using
epidemiological data from the 2007 National Survey of Mental Health and
Wellbeing.

Method

Logistic regression analyses examined patterns and correlates of service
use in two populations: people who used the new psychological services in
the previous 12 months; and people with any ICD–10 12-month affective and
anxiety disorder, regardless of service use.

Results

Most (93.2%) Better Access psychological services users had a 12-month
ICD–10 mental disorder or another indicator of treatment need. Better
Access users without affective or anxiety disorders were not more
socioeconomically advantaged, and received less treatment than those with
these disorders. Among the population with affective or anxiety
disorders, non-service users were less likely to have a severe disorder
and more likely to have anxiety disorder, without a comorbid affective
disorder, than Better Access users. Better Access users comprised more
new allied healthcare recipients than other service users. A substantial
minority of non-service users (13.5%) had severe disorders, but most did
not perceive a need for treatment.

Conclusions

Better Access does not appear to be overservicing individuals without
potential need or contributing to social inequalities in mental
healthcare. It appears to be reaching people who have not previously
received psychological care. Treatment rates could be improved for some
people with anxiety disorders.

Depression is common in old age and is associated with risk of dementia,
but its neuropathological correlates in the community are unknown.

Aims

To investigate for the first time in a population-representative sample
of people with no dementia the association between depression observed
during life and neurofibrillary tangles, diffuse and neuritic plaques,
Lewy bodies, brain atrophy and cerebrovascular disease found in the brain
at post-mortem.

Method

Out of 456 donations to a population-based study, 153 brains were
selected where donors had no dementia measured in life. Alzheimer and
vascular pathology measures, Lewy bodies and neuronal loss were compared
between those with (n = 36) and without
(n = 117) depression ascertained using a fully
structured diagnostic interview during life. Brain areas examined
included frontal, parietal, temporal and occipital cortical areas as well
as the entorhinal cortex, hippocampus and brain-stem monoaminergic
nuclei.

Results

Depression was significantly associated with the presence of subcortical
Lewy bodies. No association was found between depression and
cerebrovascular or Alzheimer pathology in cortical or subcortical areas,
although depression was associated with neuronal loss in the hippocampus
as well as in some of the subcortical structures investigated (nucleus
basalis, substantia nigra, raphe nucleus).

Conclusions

Late-life depression was associated with subcortical and hippocampal
neuronal loss but not with cerebrovascular or Alzheimer pathology.

Impaired neuropsychological function and differences in facial emotion
processing are features of major depression. Some aspects of these
functions may change during treatment and may be useful in assessing
treatment response, even at an early stage of treatment.

Aims

To examine early and later changes in neuropsychological functioning and
facial emotion processing as potential markers of treatment response in
major depression.

Method

In total, 68 newly admitted in-patients with a primary diagnosis of major
depression and 50 healthy controls completed an assessment, including
mood ratings, neuropsychological measures and facial emotion processing
measures at three time points (baseline, 10–14 days and 6 weeks).

Results

Pervasive neuropsychological impairment was evident at baseline in
patients with depression compared with healthy controls. During 6 weeks
of treatment, only simple reaction time, verbal working memory and the
recognition of angry facial expressions showed differential change in
those whose depression responded to treatment compared with treatment
non-responders in the depression group. None of the measures showed a
significant difference between treatment responders and non-responders at
10–14 days.

Conclusions

Despite significant impairment in neuropsychological functioning in the
depression group, most measures failed to differentiate between treatment
responders and non-responders at 10–14 days or at 6 weeks. Simple
reaction time, verbal working memory and recognition of angry facial
expressions may be useful in assessing response in severe depression but
probably not at an early stage.

In addition to the health burden caused by mental illnesses, these
conditions contribute to economic disadvantage because of their impact on
labour force participation.

Aims

To quantify the cost of lost savings and wealth to Australians aged 45–64
who retire from the labour force early because of depression or other
mental illness.

Method

Cross-sectional analysis of the base population of Health&WealthMOD,
a microsimulation model built on data from the Australian Bureau of
Statistics' Survey of Disability, Ageing and Carers and STINMOD, an
income and savings microsimulation model.

Results

People who are not part of the labour force because of depression or
other mental illness have 78% (95% CI 92.2–37.1) and 93% (95% CI
98.4–70.5) less wealth accumulated respectively, compared with people of
the same age, gender and education who are in the labour force with no
chronic health condition. People who are out of the labour force as a
result of depression or other mental illness are also more likely to have
the wealth that they do have in cash assets, rather than higher-growth
assets such as superannuation, home equity and other financial
investments.

Conclusions

This lower accumulated wealth is likely to result in lower living
standards for these individuals in the future. This will compound the
impact of their condition on their health and quality of life, and put a
large financial burden on the state as a result of the need to provide
financial assistance for these individuals.

Recent meta-analyses have raised concerns about the replicability of gene
× environment interactions involving the serotonin transporter gene
(5-HTTLPR) in moderating the associations between adverse life events and
mental disorders.

Aims

To use data gathered over the course of a 30-year longitudinal study of a
New Zealand birth cohort to test the hypothesis that the presence of
short (‘s’) alleles of 5-HTTLPR are associated with an increased response
to life stress.

Method

Participants were 893 individuals from the Christchurch Health and
Development Study who had complete data on: the 5-HTTLPR genotype;
psychiatric disorders up to the age of 30; and exposure to childhood and
adult adverse life events.

Results

A series of 104 regression models were fitted to four mental health
outcomes (depressive symptoms, major depression, anxiety disorder and
suicidal ideation) observed at ages 18, 21, 25 and 30 using 13 measures
of life-course stress that spanned childhood and adult stressors. Both
multiplicative and additive models were fitted to the data. No evidence
was found that would support the hypothesis that ‘s' alleles of 5-HTTLPR
are associated with increased responsivity to life stressors.

Conclusions

The present findings add to the evidence suggesting that it is unlikely
that there is a stable gene × environment interaction involving 5-HTTLPR,
life stress and mental disorders.

Little research has been conducted on the factors that may explain the
higher rates of mental health problems in United States National Guard
soldiers who have deployed to the Iraq War.

Aims

To examine whether financial hardship, job loss, employer support and the
effect of deployment absence on co-workers were associated with
depression and post-traumatic stress disorder (PTSD).

Method

Cross-sectional data were obtained from 4034 National Guard soldiers at
two time points. All measures were assessed by self-report.

Results

The four factors were associated with depression and PTSD, with
variability based on outcome and time point. For example, job loss
increased the odds of meeting criteria for depression at 3 and 12 months
and for PTSD at 12 months; the negative effect of deployment absence on
co-workers increased the likelihood of meeting criteria for PTSD, but not
depression, at both time points.

Conclusions

The findings demonstrate that National Guard soldiers have unique
post-deployment social and material concerns that impair their mental
health.

There has been little research into the prevalence of mental health
problems in lesbian, gay and bisexual (LGB) people in the UK with most
work conducted in the USA.

Aims

To relate the prevalence of mental disorder, self-harm and suicide
attempts to sexual orientation in England, and to test whether
psychiatric problems were associated with discrimination on grounds of
sexuality.

Method

The Adult Psychiatric Morbidity Survey 2007 (n = 7403)
was representative of the population living in private UK households.
Standardised questions provided demographic information. Neurotic
symptoms, common mental disorders, probable psychosis, suicidality,
alcohol and drug dependence and service utilisation were assessed. In
addition, detailed information was obtained about aspects of sexual
identity and perceived discrimination on these grounds.

Results

Self-reported identification as non-heterosexual (determined by both
orientation and sexual partnership, separately) was associated with
unhappiness, neurotic disorders overall, depressive episodes, generalised
anxiety disorder, obsessive–compulsive disorder, phobic disorder,
probable psychosis, suicidal thoughts and acts, self-harm and alcohol and
drug dependence. Mental health-related general practitioner consultations
and community care service use over the previous year were also elevated.
In the non-heterosexual group, discrimination on the grounds of sexual
orientation predicted certain neurotic disorder outcomes, even after
adjustment for potentially confounding demographic variables.

Conclusions

This study corroborates international findings that people of
non-heterosexual orientation report elevated levels of mental health
problems and service usage, and it lends further support to the
suggestion that perceived discrimination may act as a social stressor in
the genesis of mental health problems in this population.

Patient overcrowding and violent assaults by patients are two major
problems in psychiatric healthcare. However, evidence of an association
between overcrowding and aggressive behaviour among patients is mixed and
limited to small-scale studies.

Longitudinal study using ward-level monthly records of bed occupancy and
staff reports of the timing of violent acts during a 5-month period in 90
in-patient wards in 13 acute psychiatric hospitals in Finland. In total
1098 employees (physicians, ward head nurses, registered nurses, licensed
practical nurses) participated in the study. The outcome measure was
staff reports of the timing of physical assaults on both themselves and
ward property.

Results

We found that 46% of hospital staff were working in overcrowded wards, as
indicated by >10 percentage units of excess bed occupancy, whereas
only 30% of hospital personnel were working in a ward with no excess
occupancy. An excess bed occupancy rate of >10 percentage units at the
time of an event was associated with violent assaults towards employees
(odds ratio (OR) = 1.72, 95% CI 1.05–2.80; OR = 3.04, 95% CI 1.51–6.13 in
adult wards) after adjustment for confounding factors. No association was
found with assaults on ward property (OR = 1.06, 95% CI 0.75–1.50).

Conclusions

These findings suggest that patient overcrowding is highly prevalent in
psychiatric hospitals and, importantly, may increase the risk of violence
directed at staff.